1

Inter-Agency Knowledge, Attitudes and Practices Study

of Syrian Refugees in Host Communities in North

Jordan

Study Report

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Contents

Executive summary (top lines): ........................................................................................................... 3

1. Introduction: ............................................................................................................................... 4

2. Survey Methodology ................................................................................................................... 4

3. Analysis and Key Findings ........................................................................................................... 6

3.1 Demographic Profile ................................................................................................................ 6

3.2 Shelter and Accommodation ..................................................... Error! Bookmark not defined.

3.3 Income and Expenditure ............................................................ Error! Bookmark not defined.

3.4 Water Access ........................................................................................................................... 12

3.5 Water Storage ......................................................................................................................... 13

3.6 Hand-Washing ......................................................................................................................... 14

3.7 Personal Hygiene .................................................................................................................... 16

3.8 Access to Personal Hygiene .................................................................................................... 18

3.9 Food Consumption Patterns ................................................................................................... 21

3.10 Food Hygiene ........................................................................................................................ 23

3.11 Sanitation – Solid Waste Management................................................................................. 25

3.12 Sanitation – Household Level (latrines) ................................................................................ 26

3.13 Health – Communicable Disease Prevalence at Household Level ........................................ 28

3.15 Access to Communication ..................................................................................................... 31

4. Conclusion, Policy Recommendations and Key Challenges ...................................................... 32

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Executive summary (top lines):

A study was conducted in March-April 2013 to assess the knowledge, attitudes and practices of refugees living in host communities in Jordan regarding water, sanitation and hygiene. The following key findings were found:

Registration does not affect whether family / refugee receives further aid assistance from

other agencies (for example through in-kind distribution)

Most reported that their monthly income does not cover their monthly expenditure, with

the burden experienced greatest by lower-income households. Household expenditure is

primarily targeting food and rent, with WASH needs not being prioritised in household

expenditure.

More than three quarter of the survey population face issues in accessing hygiene items.

They are coping either by sacrificing other things like education or they rely on charities,

friends and / or relatives. People purchase mostly soap, laundry soap and shampoo as most

essential hygiene items. The main income sources of those families are casual labour or WFP

food vouchers. The number of small children does not impact whether the households face

issues in obtaining hygiene items.

More than half of the assessed refugee population report difficulties to bathe. Main barriers

for bathing are the cost of soap and lack of water.

Key times for hand washing are “before cooking food” (78%) and “whenever they look / feel

dirty” (78%), only 43% report to wash their hands before eating. People use water and soap

for hand washing (84%) which has been mainly confirmed through the household

observation (soap was in 75% of assessed households present). However, a considerable

number (45%) reports to face hand washing issues which is primarily due to the cost of soap

(34%) and lack of water (24%).

Food is kept mostly hygienically at household level (62%). Those households storing meat in

unhygienic conditions consume leftovers mainly within 8 hours (66%).

A large majority use the municipal solid waste system (84%), more than a half of those

households (55%) uses it to avoid any spread of diseases.

Most of the survey participants rate the condition of their toilets as “good” (72%). The main

issue observed is the bad smell (15%).

Food is mainly purchased through cash or WFP food vouchers, a larger percentage also

reports to use credit.

More than half of the survey respondents (65%) indicate to eat less than compared to Syria.

Regardless of the age, people have mostly three meals a day. Overall, the diet can still be

considered as healthy: milk products and vegetables are on average consumed four days per

week , cereals on a daily basis; meat / poultry, fruits and fish / seafood are eaten only once

per week.

Few respondents know about causes of diarrhoea, especially in terms of faeces and dirty

hands. The majority treat diarrhoea at health centre level, followed by ORS.

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The majority of survey respondents (61%) access health information through informal

channels such as family and/or friends or community discussions, although most of them

express the preference to receive such information through TV spots /shows or in hospitals /

clinics.

1. Introduction:

The study seeks to better understand the situation of the estimated 168,538 registered and

113,444 unregistered refugees living outside Zaatari camp in March 2013. The focus is on water,

sanitation, and hygiene (WASH), with a secondary focus on basic demographics, livelihoods, shelter,

and food security. The findings are beneficial to the humanitarian community at large engaged in

relieving the effects of the Syrian crises. While the KAP study was undertaken in March/April 2013,

humanitarian organisations working in host communities perceive that the knowledge, attitudes and

practices of the refugee population has not changed substantially. There has been expansion in the

number of organisations and scope of humanitarian assistance being provided to off-camp refugee

populations, however there are still gaps remaining.

With substantial resources still required to support the emergency response to the Syrian crisis,

the KAP survey seeks to identify the most vulnerable Syrian populations, the key risk factors, and the

specific needs of the refugee population. The UNHCR has projected that over 1 million Syrian

refugees could seek shelter in Jordan by December 2013.

The survey is the collaboration of the WASH working group partners including Relief

International, Oxfam, and ACTED. UNICEF primarily funded the survey and collaborated as the sector

lead for WASH. Co-contributions and joint-implementation of the study were conducted by Relief

International, Oxfam and ACTED. The study investigated demographics as well as the categories of

water, personal hygiene, and hygiene non-food items (NFIs). This report summarizes the findings

and includes recommendations for action.

At the time a lot of information was known about the needs and context of refugees in Za’Atari

camp, however little was known about the majority of refugees actually living off-camp, spread out

in host communities across Jordan. These remain relatively hard-to-reach populations and are more

difficult to locate for assistance. In addition, unregistered refugees do not receive the tents, NFIs,

medical care, and food vouchers registered refugees receive upon arrival into the camps. With

limited jobs available, increased rent prices in North Jordan, and the Syrian crises persisting into a

third year, refugees living outside of the camp are exhausting their resources.

2. Survey Methodology

The methodology was based on a common and collaborative approach, developing the study focus based on collective experience working with the target population. Survey was designed to assess different dimensions affecting refugee’s wellbeing, feeling of dignity, public health risks, and coping capacities. Specific topics covered include:

- Demographics and livelihoods - Water - Personal hygiene and access to hygiene items

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JORDAN

SYRIA

EGYPT

IRAQ

WESTBANK

ISRAEL

SAUDIARABIA

LEBANON

= Urban areas of governorates surveyed

- Solid waste and environmental sanitation - Food sources, food consumption and food hygiene - Health - Channels of communication

The study used quantitative and observational study techniques, assessing the needs of the sample

population of over 2475 surveys. The target population for the survey was Syrian refugees living in

urban and rural Irbid, Ajloun, Jerash, Mafraq and Balqa.

Sample population

Random sampling of the REACH database of refugees in host communities was undertaken to derive

a representative sample of the refugee population living in different contexts in host communities.

The random sampling methodology and the selected sample size guarantees statistically

representative results for sub-groups living in rural and urban areas of each governorate. A

confidence level of 95% was aimed at, and 99% of the intended sample size (2500) was reached.

From each area, households (HHs) were

randomly selected to be included in the

survey. Refugees residing inside the refugee

camps were excluded as previously stated.

Refugees were not excluded based on

registration status with the UNHCR, amount

of time in Jordan, financial status, etc.

Geographical Coverage

The assessment focused on the north area of

Jordan, where the largest number of refugees

currently lives in the country. The survey

covered the urban and rural areas of Irbid,

Ajloun, Jerash, Mafraq and Balqa.

Survey implementation

The content and geographic area of the survey was planned and continually updated during the

weekly WASH working group meetings. Oxfam led the two-day training on February 27 and 28 for

the 20 enumerators representing Relief International. There were 5 males and 15 females. Half of

the enumerators were Jordanian and half were Syrian. The training was in Arabic and English and

instructed the enumerators on the purpose of the survey, survey questions, proper survey

techniques, and the resolution of potential obstacles.

To further strengthen and streamline the surveys, the enumerators also attended a workshop on

March 6, 2013, where they were able to discuss effective survey methods and any unique situations

they encountered while conducting the surveys.

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Data Collection

The survey took place from March to April with twenty enumerators piloting the survey for 80

households on March 3, 2013. Based on the feedback from the enumerators and WASH working

group members, a final version of the survey was created and launched on March 4, 2013.

Enumerators initially surveyed 3-5 households per day until they were more experienced and could

complete eight per day with each survey taking 30 to 45 minutes. Surveys were taken and recorded

in Arabic and took place in confidential settings of the respondent’s choice.

Governorate End of assessment # of HHs Sample Size

Irbid Urban March 5106 225 Irbid Rural March 3794 379 Jarash Urban March 529 121 Jarash Rural March 501 73 Aljun Urban April 56 37 Aljun Rural April 638 277 Balqa’ Urban April 174 80 Balqa’ Rural April 1329 243 Mafraq Urban Dec 1573 309 Mafraq Rural Dec 1411 303

Data-entry and analysis

The paper-form was submitted to ACTED/REACH who undertook the data-entry and database

compilation. Relief International engaged the support of Palantir to support in database

management and data analysis utilising their patented software and complemented by additional

excel analysis. Joint data analysis and results finding and compiling the report was undertaken by

Relief International, ACTED and Oxfam.

3. Analysis and Key Findings

3.1 Demographic Profile

Basic demographic information was collected about surveyed households and the respondent. 51%

of respondents were female and 49% male. 52% of respondents were 18-35 years of age, 40% were

36-59 years and 8% over 60 years.

The registration status of households surveyed demonstrates a potential vulnerability and barrier of

access to services, with 10.4% of households reporting no UNHCR registration, and 22.9% reporting

that they were awaiting registration. 67% reported registration with UNHCR.

Status of UNHCR registration amongst survey respondents

Awaiting registration 22.90%

Not registered 10.40%

Registered 66.69%

There was substantial variation in reported registration levels across the governorates – with only

49% of respondents from Balqa reporting UNHCR registration and 32% awaiting registration. This is

compared to Mafraq where 71% of respondents reported UNHCR registration and 20% awaiting

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registration. There was higher rates of UNHCR registration reported in urban areas (73%) compared

to 63% in rural areas.

UNHCR registration status by Governorate

Ajloon Balqa Irbid Jarash Mafraq Total

Awaiting registration 24.26% 32.12% 18.00% 29.33% 19.68% 22.90%

Not registered 8.85% 18.18% 6.51% 13.49% 9.64% 10.40%

Registered 66.89% 49.70% 75.49% 57.18% 70.68% 66.69%

42% of respondents reported being registered with or receiving assistance from organisations other

than UNHCR, with the lowest rate recorded in Balqa (24%) and the highest rate in Jerash (49%). The

low levels of registration with both UNHCR and other organisations in Balqa demonstrate a potential

vulnerability for refugees residing there. A range local, national, and international organisation was

referenced.

Of all respondents 67% reported registration with UNHCR, 10% registration with other organisations,

and 23% not registered at all.

The majority of respondents reported having lived in Jordan for 6-12 months (46%) and 3-5 months

(25%). Very few respondents were new arrivals to Jordan (6%).

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The length of stay trends by governorate were similar, with on average 56% of respondents

reporting living in Jordan for over 6 months. Irbid reported a greater proportion of longer-term

residents (70%) and Ajloon the lowest (44%). Ajloon reported the greatest proportion of new arrivals

(26.4%) compared to 6% in Irbid and a national average of 19%.

During this time 41% of respondents had not left their initial place of residence in Jordan, 33% had

previously lived in Za’Atari camp or other transit facilities, and 26% reporting having lived in another

location. Of those living in urban areas, a smaller proportion reported having lived in Za’Atari camp

(23%) compared to 34% of rural respondents. This could infer a slightly different demographic

moving to urban areas compared to rural areas.

16% of respondents reported that a member of their household had a disability – the majority of

which was physical disability (62.5%).

3.2 Shelter and Accommodation

Renting was the primary accommodation arrangement of respondents (85%). This varied slightly

between rural (82%) and urban (89%). 8% of total respondents reported other – living in tents. This

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was also much more likely amongst rural respondents (13% of rural respondents compared to 1% of

urban respondents).

Shelter type reported by respondents

Type of shelter

Proportion of

respondents

Hosted by Charity/relief

Organization 1.4%

Hosted By Jordanian Family 1.6%

Hosted by Syrian Family 2.2%

Hosted in Jordanian Gov't building 0.2%

Living in Vacant/Unfinished

property 0.5%

Not Answered 1.4%

Tent 7.6%

On a farm 0.5%

Renting (JD/Month) Specify 84.6%

The study observed that 80% of respondents were residing in apartments or homes, with an

additional 4% living in single rooms in an apartment or house. 8% of respondents were observed

living in tents/temporary shelters.

3.3 Income and Expenditure

Respondents were asked to rank their main source of income generation. Of the 2239 respondents

who answered the question, 56 (less than 1%) reported no income source at all. The primary income

sources that were identified as at least 1 source of income for the household was casual labour

(42%), WFP cash/ food vouchers (40%), drawing down on savings (21%), support from family and

friends (19%), and other NGO charities (18%). 11% of respondents reported selling assets as one of

their income sources. The least reported income source was small business (1%) and skilled labor

opportunities (5%). These results indicate that the Syrian refugee population has very little formal

income-generating opportunity; however there appears to be informal work opportunities in the

host community markets. In aggregate, the primary support is coming from institutional support or

relying on their existing resources (savings, family/friends).

Proportion of respondents who reported the income

source as at least 1 of their income sources

Income Source Proportion

Small business 1%

Skilled labor 5%

Sell/donate items 6%

Remittance 7%

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Cash assistance 10%

Sold assets 11%

Other NGO charity 18%

Family/Friends 19%

Savings 21%

WFP cash/food vouchers 40%

Casual labor 42%

The majority of respondents (46%) reported incomes of 200-399JD per month, 34% of respondents

reported monthly incomes of under 200JD per month, and 7% reported no income at all.

The average difference between income and expenditure across the respondents was -172JD,

implying that most households are spending more than they earn.

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Most respondents said they incurred the highest expenditure on food (130JD), rent (121JD), and

food WFP vouchers (51JD).

The self-reported coping capacity was reported as very low by most respondents – with 97% of

respondents reporting that with their current sources of income, support and accessible resources

could manage for less than a month. There was no significant variation between rural and urban

respondents or across the governorates (ranging from 93% in Irbid and 98% in Mafraq).

Based on your current sources of income and support and accessible resources, for how long can you continue to manage to live where you are?

Length of coping time Proportion of respondents

< 2 weeks 49.33%

1 - 2 months 15.08%

2 - 3 months 3.68%

2 - 4 weeks 28.55%

3 - 4 months 1.43%

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4 - 5 months 0.78%

More than 5 months 1.15%

3.4 Access to clean drinking water.

Typical question asked: Where does your HH get water for drinking and bathing/washing (all other uses)?

- 77% of respondents reported receiving piped water (1861/2421), 31% of whom reported receiving piped drinking

water and 69% only for other purposes.

o Ajloon and Jerash had the highest number of respondents receiving piped water (91% and 87%

respectively) compared to Balqa where 55% were receiving piped water. The proportion of respondents

receiving piped water in Irbid and Mafraq were both 76%. The rest of the population in Ajlon, Jerash,

Balqa and Mafraq get water from unknown sources.

o Respondents in urban areas were more likely to have access to piped water (all purposes) than rural

areas in all governorates (average 60% in rural areas compared to 40% in urban areas reported

receiving piped water).

- 61% of respondents reported purchasing bottled water for drinking. It was least common to purchase water in

Mafraq (38%) and Balqa (56%), whereas in the other governorates approximately ¾ of respondents reported

purchasing bottled water. Refugees living in urban environments were more likely to purchase bottled water for

drinking than those living in rural areas (68% in urban compared to 55% in rural). Very few reported purchasing

bottled water for purposes other than drinking (4%). Purchasing bottled water for cooking/cleaning/bathing could

imply high vulnerability of water access – 60% of those reporting purchasing water for purposes other than

drinking reported total monthly incomes of 200JD or less.

- Only 30% of respondents reported purchasing water from a private water tanker (it was more common in rural

areas (33%) than urban areas – (21%). Balqa and Ajloon had the highest rate of water tank use (39% and 34%)

compared to the other governorates (Mafraq – 28%, Irbid – 27% and Jerash 24%). The majority of households

were using it not for drinking but for other purposes.

-

Typical question asked: Does your HH have access to enough water to meet basic needs?

- Half of total respondents reported they had access to enough to meet basic needs, while the other half reported

they did not. The most commonly reported coping mechanism for people without adequate water to meet basic

needs was to purchase water (72%), followed by receiving from neighbours (18%), and followed by waiting (10%).

There was no substantial difference between perceptions of adequacy of water across the governorates. However

Urban respondents across all governorates reported higher levels of adequacy of water access compared to rural

areas (41%-rural compared to 59% urban).

Household Perception of water quality

- The majority of respondents reported perceptions of water quality as average, with slightly

more respondents reported their water qualities as good/very good quality (29%) compared

to those that reported their water qualities as bad or very bad(24%). Only 7% of respondents

had their perceptions of their water qualities as “very bad”. Jerash and Mafraq had slightly

lower perceptions of water quality (67% and 70% of respondents reported

average/good/very good water) compared to Ajloon, Balqa and and Irbid (74% of

respondents reported average/good/very good water quality perception).

For those reporting Bad/Very bad water quality – primary actions taken:

Boil 3.99%

Buy bottled water 0.19%

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Filter 1.52%

Other 0.76% Think it is bad/very bad but do nothing 27.76%

Use bottled water instead 65.78%

Grand Total 100.00%

Current waiting times taken by households to fetch water.

- The wait time for respondents to access water was reported as follows:

Wait time Number Proportion

<20mins 192 10%

21-40mins 51 3%

41-60mins 64 3%

>60mins 102 5%

NA - piped water 1659 83%

Total 2006 100%

3.5 Household Water Storage Practices.

- Respondents reported the following types of water storage systems being utilized. Jerry cans

were identified as the primary water storage device (45%) followed by large covered

containers (21%) and covered buckets/pots/containers (13%).

Water Storage Device Relative use of water storage devices reported by respondents

Bucket/pot/container covered 13%

Bucket/pot/container uncovered 2%

Jerry can 45%

Large covered container 21%

Large uncovered container 2%

Plastic bottles 7%

Other 10%

Grand Total 100%

The analysis of sizes of household water storage devices reported by respondents that do not have

access to piped water are outlined in the table below, with the majority of respondents reporting

household water storage capacity of 21-40litres (54%) followed by 18% who have 121-140 litres.

The survey didn’t find any correlation between household size and water storage capacity.

Water storage capacity at household level

101 - 120 litres 2.07%

121 - 140 liters 5.20%

21 - 40 liters 15.50%

41 - 60 liters 1.16%

61 - 80 liters 2.31%

81 - 100 liters 2.50%

Not Applicable (has piped water)

71.26%

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Grand Total 100.00%

Cleanliness of household water storage containers

- The majority of respondents reported poor practices of maintaining cleanliness of small

water storage devices, either never washing their small water storage containers (38%) or

washing them less than once a week (16%). 22% reported washing them every day and 24%

a few times a week.

- Cleanliness of large water storage devices reported by respondents was worse – with nearly

80% reported either never washing their storage units or washing them less than once a

year. 7% reported washing them 1-2 times a year and 15% reported washing them 3-4 times

a year.

Household Water collection practices.

- As noted previously, the majority of respondents (65%) had access to piped water in their

home and so reported not using water collection devices. Of those who were collecting

water from public water points, the vast majority reported using jerry cans as their main

water collection device (70%) followed by buckets or other open containers (15%) and

plastic water bottles (15%).

- Of those collecting water, 83% reported using the same container to collect and store water,

with only 17% maintaining safe/hygiene separation of water collection and storage devices.

3.6 Current Hand-Washing Practices.

The majority of the survey participants practice hand washing before food preparation (78.3%) and

whenever they look or feel dirty (78.3%).

The results also show that a larger number of respondents considers hand washing before praying

more important than before eating. More than a half of the respondents indicate to wash their

hands after defecation (58.61%). A smaller percentage washes their hand before feeding a child /

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breastfeeding (17.67%). The analysis against the urban and rural survey population shows that there

generally slightly more urban respondents wash their hands on key times. For example, whilst 43%

of the urban survey participants wash their hands before eating, 49% of the urban reported to do so.

Hand washing moments according to gender

Moment Male Female

Before cooking 48.71% 51.29%

Whenever they look / feel dirty 48.71% 51.29%

Before praying 48.04% 51.96%

Yes after defecation 49.43% 50.66%

Yes before eating 47.36% 52.64%

Yes after eating food 46.96% 53.04%

Yes before feeding a child / breastfeeding 31.40% 68.60%

Slightly more women than men wash their hand at key moments such as before eating, after

defecation or before food preparation. The only exception represents the moment before feeding

the child / breastfeeding which is less surprising considering the cultural context in which women are

mainly responsible for children’s care.

A large number of respondents point out to wash their hands with water and soap, slightly more of

them are urban. These results are mainly confirmed by the household observation, as in the majority

of the households soap was present when the enumerator asked to wash the hands.

In 18.47% of the cases hand washing

seems to be carried out with water

only. 32% of the respondents

reporting to wash their hands with

water only are facing difficulties to

access soap due to the cost. The

observation revealed further that

only a small percentage of the

assessed household does not have

access to a designated hand

washing area. In rural areas a lower

percentage had soap present (65% against 77% in urban settings. More than a half of the survey

respondents indicate to not face any difficulties for washing their hand. Interestingly, those

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reporting problems accessing soap, reported to wash their hands after defecation than those who

did not identify the cost of soap as barrier to hand washing. Those who report that hand washing is

problematic identify the cost of soap and the lack of water as main barriers for hand washing at key

times. Small number indicates that the washing area is either too far or inconvenient to practice

hand washing at key times during the day.

Households facing difficulties to wash their hands report still to wash hands with water and soap

although soap is becoming too expensive. The observation revealed that in 64.36% of the

households soap was present. In 10.67% of the households assessed no designation hand washing

area was available.

The incidence of diarrhoeal diseases in households facing difficulties to wash their hands is not

significant in comparison to the total number of diarrheal cases.

In relation to households who have

difficulties in obtaining hygiene

items, 41% of the respondents

indicate that the main barrier to

hand washing is due to the lack of

water and 42% due to the cost of

soap.

A fewer number (17%) of the survey

participants explain that the lacking

hand washing area is the main

reason for facing issues washing

hands.

The majority of the households reporting issues to wash their hands receive health information

mainly through informal channels. Most of them get informed by family and friends (41.09%) or

community discussions (32.30%).

3.7 Finding on Personal Hygiene Practices.

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More than the half

(59.23%) of the survey

population faces issues to

bath on a regular basis.

The main barriers for

bathing are the cost of

soap (19.34%), followed by

the lack of water (18.09%).

When comparing answers

of urban and rural survey

population and those

facing difficulties in

bathing due to the coast of

soap, the survey results show that there are no significant differences. However, rural respondents

reported higher difficulties to bath due to the lack of water (37% compared to 27%). The lack of

privacy is rather an issue for women (8.27%) than for men (6.35%).

A small percentage (6.86%) also indicates that the place of the washing area is either far or

inconvenient (for example for those living in a tent). Those households which report to face

difficulties in purchasing hygiene items and also in bathing identify the water temperature as main

obstacle (37.38%) 1as well as the lack of water (31.24%). More than a quarter (26.33%) indicate that

the cost of soap makes it difficult for them to bath on a regular basis, while 15.55% thinks that the

washing area is too far or too inconvenient. The number of women feeling that the lack of privacy is

an issue is higher for those who have limited access to purchase hygiene items on a regular basis

(15.14%).

1 During the start of the survey period in beginning of March the outside temperature were still low.

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Among the total number of assessed households 31% report to face difficulties in bathing due to lack of water. The majority of the

assessed households do report to have issues to brush their teeth. The difficulty is primarily linked

to the lack of toothpaste (26.66%) and toothbrush (19.61%). The results lead further to the

conclusion that also the lack of water constitutes a major barrier to teeth brushing (12.6%)

The table highlight the fact that those households with difficulties to brush their teeth, only a small

percentage received toothpaste and toothbrush, hence more than the half of the this survey

population group purchased these items. Among those who inidcate to have difficulties to rush their

teeth also have limited access hygiene items.

3.8 Findings on Personal Hygiene Practices

Households having issues to brush their teeth

Purchased Toothpaste 60%

Purchased Toothbrush 54%

Received Toothbrush 7%

Received Toothpaste 8%

Having difficulties to obtain hygiene items 59%

Hygiene items received through distribution

No Items Received 23.86%

Soap 13.05%

Washing Powder 12.61%

Shampoo 10.52%

Toothpaste 7.40%

Toothbrush 6.38%

Sponge 3.26%

Comb 3.21%

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More than three quarter of the survey

participants have received hygiene items

through distribution. However, the

answers suggest that the hygiene items

haven’t been distributed in an equal and

standardized manner.

For example, soap is one of the basic

hygiene items and according to Sphere

Standards the minimum amount shall

cover the monthly needs of one person

(250gr), however only 13% of the

assessed households received soap. Very

few households were supported in terms of baby items (2.58%) and the needs in terms of female

hygiene are far from being met, as only 1.8% reported to have received sanitary napkins

(disposable).

The survey results show further that there is a significant difference among the urban and rural

population having received hygiene items, due to the higher proportion of rural survey participants.

Whilst 9% of the rural population received soap, 16% were urban, which indicates an under

provision of the rural population. This represents the average among those items which were most

distributed.

More than the half of the households (57%) which haven’t received any hygiene items are registered

with UNHCR, 31% is waiting for registration and 12 % unregistered. This leads to the assumption that

the refugee status does not have a direct impact on receiving aid assistance in terms of NFI

distributions.

Further, the survey results reveal that the majority of the survey participants are not able to meet

their needs in terms of hygiene items. A large percentage (40%) indicates to have the ability to meet

their needs in terms of hygiene items only by scarifying other things like education, clothing or

heating. This is consistent among the rural and urban setting the survey participants are living in and

also the case for the other answer categories assessed.

Jerry Cans 2.63%

Disposable Childs Diapers 2.58%

Towels 2.48%

Buckets/basins 2.39%

Nail Clippers 1.90%

Brush 1.80%

Disposable Sanitary Napkins 1.80%

Washing Cloths 1.22%

Wet Wipes 0.97%

Household Water Storage 0.73%

Ear Swabs 0.54%

Dish Soap 0.10%

Other 0.58%

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One quarter (24.64%) have the ability to meet their needs but partly relying on what other

organizations and / or people provide to them. A smaller percentage (13.76%) reports to rely

completely on other people and / or organizations. 26.3% of those who face issues with obtaining

hygiene items report to face also difficulties in terms of bathing because of the lack of soap.

According to the survey results, soap, washing

powder and shampoo are considered as top

priority hygiene items.

More than the half of these households

(52.59%) purchase toothpaste and 47.05%

toothbrush.. One third (34.47%) indicate to

purchase disposable sanitary napkins. Baby

diapers also belong as well to the items mostly

purchased at household level (47.09%),

especially in those counting with small

children.

The income sources of the household which

facing limited access to hygiene items do vary.

Most of them draw financial resources from

casual labour (24%) or WFP Food vouchers

(21%). Informal support channels also

constitute an important income factor, either

provided by the host family or friends (17%). A

smaller percentage has still access to saving

(10%) whilst only few get cash assistance

either through other NGO’s / charities (8%) or

UNHCR (6%). Only a small percentage is living from remittances or sold assets and 2% admit to sell

donated items to make their survival.

Hygiene items purchased for personal or HH use

Soap 94.77%

Washing Powder 94.28%

Shampoo 87.15%

Toothpaste 52.59%

Disposable Childs Diapers 47.90%

Toothbrush 47.05%

Comb 46.34%

Jerry Cans 46.30%

Sponge 43.55%

Nail Clippers 40.36%

Disposable Sanitary Napkins 34.47%

Brush 30.93%

Towels 30.44%

Buckets/basins 27.25%

Washing Cloths 26.23%

Ear Swabs 25.34%

Wet Wipes 22.29%

Household Water Storage 11.79%

Dish Soap 0.53%

No Items Purchased 0.62%

Other 0.40%

21

More than one half of the households with young children facing difficulties to obtain hygiene items

count one child (54%), followed by households with two young children (33%).

Within the households reporting limited access to hygiene items mostly children under 5 years (36%)

and adults are suffering from skin problems.

3.9 Food Consumption Patterns

Food sources

The households assessed rank “cash” as main source to purchase food (68.67%), this is the case for

both, urban and rural survey population group. This result is followed by the purchase of food

through WFP vouchers (57.76%). More households in urban areas (29%) report to use WFP food

vouchers (24% in rural areas). A large percentage purchases food as well on credit (46.34%). Only

few people count (17.44%) on the support from NGO / charities when ranking the main food

sources. Some (12.33%) get support from friends and relatives and 12.94% borrow money to

purchase food.

22

A large number of the survey participants consider their food consumption as “less”(65%) compared

to the time back when thet lived in Syria. More than one quarter (27%) consider their food intake as

the “same”, whilst 8% report that they even consume more food than before. The analysis across

the urban and rural setting does not reveal any significant differences in terms of the food

consumption pattern.

A large percentage of children under 5

years (49.01%) have three meals or

more per day. There are no significant

differences when comparing number

of meals of urban and rural

respondents. Children aged between

6 and 17 years mostly have 3 meals

per day (83.26%), 13.86% two meals a

day. Compared to children less than 5

years this number is significantly

higher and could be explained by the

fact that family care prioritises very young children when it is about food intake. Compared to

children between 6 and 17 years, fewer adults have three meals per day (79.91%) and more only

two meals a day (17.26%).

“Meat/ poultry” belong to the top priority food groups according to the households assessed. Fewer

households (27.66%) consider “fruits” as important. The survey results indicate further that

vegetables (14.21%) and pulses / legumes / nuts (9.89%) are not considered as most important food

groups.

23

People generally report to have difficulties to eat meat / poultry on a regular basis and report to

have eaten it only one day during the last 7 days prior to the survey. More than half of the assessed

households (52.25%) indicate to use oil / fat on every day during the last 7 days. The majority of

those who had consumed fish and seafood did it once per week (83%), whilst cereals have been

used on a daily basis during the last seven days.

Average consumption of different food groups during the last 7 days prior to the survey

Food groups consumed 1 day Fish and seafood, fruits, meat and poultry

Food groups consumed 3 days: Roots and tubers, eggs, legumes, pulses, nuts

Food groups consumed 4 days Milk / milk products, vegetables

Food groups consumed 5 days Oil / fat

Food groups consumed 6 days Sugar, honey, Miscellaneous

Food groups consumed 7 days Cereals

3.10 Findings on Food Hygiene Practices.

In a large majority of the assessed households (86%), meat is stored hygienically, either in a fridge

(54.32%) or in a covered pot or container (31.75%). A large majority of the survey respondents who

store meat in the fridge is urban (70% compared to 49% for rural). People from rural areas store

meat mainly in a covered container or pot (38% in rural against 21% urban).

Storage of meat at household level

Fridge 54.32%

Covered Container Or Pot 31.75%

Bag On Ground 5.55%

Bag Off Ground 3.89%

Uncovered Container Or Pot 1.46%

At neighbour’s place 3.03%

Those households storing meat either in

a bag, uncovered and / or on the ground

24

consume it within the 8 hours. Over one third (34%) keeps it up to 24 hours. During winter time this

storage length is less likely to imply any health risks; however, with raising temperatures hygiene

promotional activities shall stress the point to store meat for the small amount of time to prepare it

for cooking. Further it should be cooked thoroughly.

The table above shows that most of the food is consumed at the very same day which is also linked

to the fact that the amount purchased and cooked are limited. A smaller number (27.59%) keeps

food longer than one to two days. In those households the leftovers are mainly kept in a covered pot

elevated from the floor (61.87%). Almost one quarter (24.71%) store leftover food in a less hygienic

manner, either directly on the floor and / or uncovered.

Observed household food storage practices

Covered In A Pot Elevated From The Floor 61.87%

Covered In A Pot On The Floor 13.42%

In A Bag Elevated From The Floor 9.82%

In A Bag On The Floor 6.71%

Uncovered Elevated From The Floor 5.56%

Uncovered On The Floor 2.62%

As for the meat, fruit and vegetables are stored either in the fridge or in a pot covered on the floor.

25

Those who report to keep vegetables in the fridge are mainly from urban areas (65% against 43%).

The primary alternative practice used of urban survey respondents to store vegetables is a covered

container or pot.

However, the observation revealed that in those households mentioned above, fruit and vegetables

are not at all stored in the fridge but rather in a covered pot elevated from the floor. This suggests a

certain knowledge-behaviour gap and reflects at the same time the elevated educational

background of the survey population providing answers as socially it would have been expected.

3.11 Findings on household Environmental Sanitation Practices– Solid

Waste Management.

Environmental sanitation

Most of the households assessed dispose

the solid waste in bags, only a few numbers

collect it directly in bins. A large majority

(84.6%) use the municipal collection system,

whilst 14.46% drop it anywhere outside.

Those households which indicate to use the

municipality system see the benefit mainly in

the preventing diseases.

A large percentage of the survey respondents consider the cleanliness of the community also as

advantage of using the municipal disposal system.

More than half of the households indicate to dispose diapers in a separate bin and / or bag, 40% use

the same trash and 5% do not use do not have diapers.

26

The observation of the households confirmed that solid waste handling at household level is mainly

done in a hygienic manner. When observing waste at household level it was mostly found outside

from the home (9.14%). No rubbish was observed in 76% of the rural households and 85% in urban

households. Rubbish is slightly more discarded inside rural homes (5% of urban households rubbish

compared to 3% in rural households). Solid waste disposal outside of the house is rather problematic

in rural areas (13% against 6% in urban areas).

3.12 Findings on Household Sanitation Practices.

The majority of the survey participants rate their toilets as functional and in a good structural state (71%), less

than a quarter consider

the condition of their toilet as “poor” (22%). A small percentage of the respondents do not their toilets

because they are not functioning (5%). 78% of urban respondents rated their toilets as “functional and in good

structural state” compared to 69% in rural areas.

In the majority of households assessed the overall conditions were good (60.65%). The main issues which

could be identified with the bad smell (14.97%).

These results are very much in line compared to the observation reports in households reporting poor or not

functioning sanitation conditions. Generally, those toilets are mainly hygienic except the presence of smell

(16.51%).

27

In 12.63% of those

assessed households flies

were present and almost

the same number

(12.51%) faces difficulties

in sanitation access due to

damages. In a smaller

number of visited

households (10.81%)

leakages, plumbing issues

or blockage could be

found. In a small number

of toilet facilities

observed, faeces were

present.

According to the survey

participants who rated the toilet facilities as poor or not functioning the main reason are a broken

infrastructure (15.07%) and inadequate infrastructure (12.47%).

For a smaller number of assessed households (7.13%) the fact that they need to share the toilet with a various

number of people and/ or water for flushing is not available represents a serious issue.

During the observation main household sanitation problems identified were due to leaking sewer /

septic tank (13.53%) or a broken sewer / septic tank system (18/29%). Only in very few households

no septic tank or connection to the sewage system was observed (2.18%).

28

A higher percentage of the urban households assessed reporting poor or not functioning had no

observed damage (53% compared to 39% in rural areas). No substantial difference was observed in

terms of a broken sewage or septic tank (14% of urban households against 17% rural households). In

terms of broken toilets it seems rather problematic in urban areas (22% in urban compared to 18%

in rural settings).

3.13 Health – Communicable Disease Prevalence at Household Level

Disease prevalence in the household

There are always issues with self-reported disease data. However, the information included in the

table below is an indication of major diseases to be focused on for prevention priorities. Seasonality

impacts on disease experience of households, and it’s important to note that this data reflects the

experience of refugees for the first few months of the year (Jan – March). It could be considered that

colds/flues/ARI would be more highly represented compared to diarrhoea and skin infections (more

common in warmer months). ARI and diarrhoea in children is the priority issue (18% of households

reported prevalence of coughing in children and 7% of diarrhoea.

Reported disease prevalence in households

Adults Adolescents Children

None Yes None Yes None Yes

Fever 94% 6% 94% 6% 87% 13%

Coughing 91% 9% 87% 13% 82.0% 18%

Vomiting 99% 1% 99% 1% 97.0% 3%

Diarrhoea 99% 1% 97% 3% 93.0% 7%

Stomach pain 96% 4% 99% 1% 98.0% 2%

Skin problems 94% 6% 96% 4% 96.0% 4%

Eye infection 98% 2% 99% 1% 98.0% 2%

29

Diarrhoea

Table: Number of households members with diarrhea in the last 2 weeks

Number of household members Age range

>18yrs 6-18yrs 2-5yrs <2yrs

0 99.33% 97.69% 93.78% 93.56%

1 0.62% 1.78% 5.15% 6.08%

>1 0.04% 0.53% 1.07% 0.36%

Prevalence of diarrhoea reported in adult members of households was low across the population

(0.66% of households for >18yrs and 2.31 for 6-18yrs). Diarrhoea reported in under children less

than 2 years was reported by 7% of households.

There was slight variation across governorates in the prevalence of diarrhoea in children less than 2

years reported, ranging between 3.5% in Jerash and 7.2% in Mafraq. Respondents in Urban Ajloun

reported higher than average number of households with children less than 2 years experiencing

diarrhoea (13.9%). However the sample size for this location is smaller. Rural Mafraq also reported

relatively higher numbers of household with diarrhoea in children less than 2 years (8.0%).

Prevalence of diarrhea in children under 2 years in the last 2 weeks by governorate and rural areas

No Diarrhea Diarrhea Total

Ajloon 274 94.2% 17 5.8% 291

Rural 243 95.3% 12 4.7% 255

Urban 31 86.1% 5 13.9% 36

Balqa 281 94.3% 17 5.7% 298

Rural 213 94.7% 12 5.3% 225

Urban 68 93.2% 5 6.8% 73

Irbid 496 93.1% 37 6.9% 533

Rural 324 93.1% 24 6.9% 348

Urban 172 93.0% 13 7.0% 185

Jarash 164 96.5% 6 3.5% 170

Rural 64 95.5% 3 4.5% 67

Urban 100 97.1% 3 2.9% 103

Mafraq 657 92.8% 51 7.2% 708

Rural 403 92.0% 35 8.0% 438

Urban 254 94.1% 16 5.9% 270

Grand Total 1872 93.6% 256 12.8% 2000

The majority of respondents did not report what actions they usually took the last time their child

experienced diarrhoea. The reported actions for responding to diarrhoea involved the following:

30

More than half of the respondents do seek medical assistance for diarrhoeal cases, whilst 26% opt to

rehydrate the child with ORS. Home-made sugar and salt solution is less common; few respondents

do choose engage in risk practices to treat diarrhoea amongst young children by providing either

more fluid containing sugar or less water.

The knowledge and awareness of the causes and risk factors for diarrhoea of respondents were low.

Most respondents were unable to provide a response to the question of “what do you or members

of your family think can cause diarrhoea.” The most common risk factors identified were unsafe

water (24% of responses) and contaminated food (19% of responses). Only 13% of responses were

“unclean hands”, and 5% were “faeces”.

Reporting of knowledge and awareness of prevention of diarrhea measures were also quite low, in

particular those associated with critical times for hand-washing.

31

3.15 Access to Communication

Communication / access to health information

More than half of the survey respondents access health information through informal channels (61%),

either through friends and/or family (33%) or through community discussions (28%). According to

the results hospitals and clinics also play an important role in terms of health information

dissemination (24%). When comparing the major sources in terms of health and hygiene there are no

significant differences between the urban and rural areas.

Communication: where do you get your health information from

Your Family/friends 33%

Community Discussions 28%

Hospitals/clinics/doctors 24%

Place Of Worship 11%

Posters/leaflets 2%

Newspaper/magazine 2%

Total

The table below reveals that there are no significant differences in terms of accessing health

information according to gender. Slightly more women get health information through family and/or

friends (54% compared to 46% of male respondents), except regarding newspapers. In this respect a

larger percentage of women (19%) receive information related to health matters.

Survey respondents

ranging between the

age of 18 and 35 years

represents the largest

group accessing the

main channels of health

information mentioned

by the total number of

assessed households.

This can be also linked

to the fact that this age

group has the easiest

32

access to different health channels as it is the most active one in comparison for example to elderly

people (more than 60 years). The small percentage of younger people receiving health information

can be explained by the fact that they constitute the smallest number of survey respondents.

Interestingly most of the survey respondents refer to preferred communication channels which are

currently only relatively few or not at all used. For example, 34% of the assessed households

expressed the interest to get health and/or hygiene information through TV spots or shows. A quarter

of households (25%) confirm that hospitals and clinics constitute an essential source for further

information dissemination. The results suggest further, that communal channels such as community

groups or places of worship shall play a less important role when planning for further health/hygiene

awareness rising.

4. Conclusion, Policy Recommendations and Key Challenges

The survey results show that most of the survey participants benefitted from some in-kind

distribution. However, only a small percentage has been covered by essential hygiene items such as

soap for hand washing or laundry. This suggests that until now the distribution of NFI kits does not

follow sector agreed standards detailing which items shall be included in a hygiene kit and that

humanitarian assistance is far from meeting the needs of vulnerable refugee households. Moreover,

the refugee status does not facilitate further inter-agency support for example in terms of NFI kits.

This can be linked to the fact that UNHCR data is not shared on an individual basis as well as the

number of unregistered refugees is still unknown and difficult to track. However, the overall

coordination sector needs to undertake continuous efforts to identify and assist most vulnerable

refugees who are above of all those who are not yet registered or awaiting registration. Support to

those households is crucial as a large majority faces issues to obtain hygiene items on a regular basis

which makes it difficult to maintain the required level of personal hygiene and hence can result in

increased public health risks. Hygiene items which are mostly purchased do include basic items such

33

as soap. However, the average hygiene kit does not consider shampoo and dish soap as being essential

and therefore not part of the standardised host community hygiene kit. It is still under discussion

whether in-kind support is cost effective or not compared to a hygiene voucher system or direct cash

support. Further decision-making is mainly influenced by the number of beneficiary who shall receive

assistance as well as the shopkeepers’ capacity and retailers’ product costs. Alternatively, additional

cash support to those households can be provided. However, as long as it is not clear how decision-

making power is allocated at household level and unconditional cash support is provided, it risks not

be allocated for hygiene items. 2

A large number of survey participants face issues in terms of maintaining personal hygiene. The cost

of soap and lack of water constitutes for vulnerable households one of the main barriers to bath.

Hence, humanitarian WASH agencies shall identify mechanisms to support households in accessing

essential hygiene items as well as water for diseases prevention but also to ensure people’s feeling of

wellbeing and dignity.

Key hand washing moments are generally understood by the survey population, especially the

moment before food preparation. Nonetheless, hygiene promotional activities should focus on raising

awareness about crucial hand washing times and the importance of hand washing for diseases

prevention. Generally, when planning any hygiene promotional activities they need to take into

account that this emergency response takes place in a middle income context in which the crisis

affected population is mainly well educated and aware about their preferences. Public health

promotion strategies for host community settings need to be differentiated when targeting people

living in standard accommodation or those in tent-based communities.

Channels for health/hygiene information dissemination should take into account that more than one

third of the survey respondents prefer to receive health / hygiene information through TV spots and/or

emissions. The planning of hygiene promotion should still consider the importance of community

discussions and apply a participatory approach but be combined with mass messaging using TV

channels for example for larger public health campaigning. Furthermore, hospitals and clinics should

be actively integrated in the promotional activities by organising specific community discussions to

epidemiological data patterns and / or according to subjects people express their main interest in

(reproductive health, water-born related diseases etc.).

In terms of environmental sanitation further assistance should look into ways to support the municipal

system to deal with an increased amount of waste as a large part of the survey population collect

garbage in a hygienic manner also in view of decreasing the spread of diseases.

The survey results show that access to sanitation facilities is less problematic in this context of

emergency response, except for people living in informal settlements. Agencies working in host

community settings should investigate further in the sanitation conditions and assessing toilet issues

reported by the targeted population. The decision whether to give infrastructural support at household

level needs be carefully analysed as any household improvement work also risks resulting in an

increased rental price and falls actually rather under the responsibility of the respective landlord.

2 If those fields are being considered as basic life needs it will be less problematic, however, the issue remains

that crucial personal hygiene items won’t be purchased which can lead to an increased incidence of WASH diseases.

34

Smaller plumber work can be carried out, for example by providing capacity building of local

associations and spare parts for the toilet structure (flush repairmen, seat etc.). In case that household

assessment reveals broken or leaking sewer systems, any work should be undertaken in collaboration

with the respective water authority to increase the awareness about potential contamination of water

supply networks. Leakage mapping of water supply networks (either larger distribution pipes or

household distribution network) could be extended to the sanitation system as well in order to plan for

timely response management.

As the majority of households indicate to purchase food by cash and WFP food vouchers the food

consumption pattern is likely to change especially for those household which are unregistered or

awaiting registration. According to the survey results the crisis affected population is still able to

maintain an acceptable level of nutritional dietary balance. The survey outcomes lead also further to

the assumption that reducing the average number of meals is not yet an applicable coping strategy.

However, when dealing with an extensive number of refugees not having access to legal employment

the situation risks to worsen as current coping strategies (loans from relatives / shop owners, selling

assets etc.) will be soon exhausted. Further advocacy work needs be undertaken to draw more

attention on the current risk situation of Syrian refugees in order to raise more funding for this

population group and facilitating the access to livelihood opportunities.

Key Findings Recommendations

WA

TER

The majority is connected to the water supply system those in urban areas have an increased access to piped water compared to the rural population.

Half of the respondents have difficulties to access enough water to meet basic needs through the water supply network.

A large percentage purchases filtered water for drinking.

The water quality is generally rated as average; those who perceive it as very bad normally purchase bottled water.

Cleanliness of water storage devices is mainly poor as they are cleaned either never or only once per year.

WASH agencies should actively engage with respective water authorities to identify priority interventions to increase access to water; alternatively water access can be increased through distribution of water vouchers and/or paying water bills of most vulnerable which requires thorough (market) monitoring;

Increasing access to water at household level through household repair work or increasing water storage capacity can be assessed, weighing costs and impact;

Water quality testing shall be undertaken, based on results and people’s preference water filters can be distributed;

Hygiene promotional activities can evolve around best practices for water conservation, assessing feasible and low-cost options for water treatment and focus on promotion of safe water chain, especially at storage level.

HY

GII

ENE

ITEM

S

Registration does not affect whether family / refugee receives further aid assistance from other agencies (for example through in-kind distribution)

Only a small percentage has been covered

Overall coordination sector needs to undertake continuous efforts to identify and assist most vulnerable refugees who are above of all those who are not yet registered or awaiting registration.

35

by essential hygiene items such as soap for hand washing or laundry

More than three quarter of the survey population face issues in accessing hygiene items, either they sacrifice other things like education or they rely on charities, friends and / or relatives.

People purchase mostly soap, laundry soap and shampoo as most essential hygiene item. The main income sources of those families are casual labour or WFP food vouchers.

The number of small children does not impact whether the households face issues in obtaining hygiene items. However, mostly children under 5 years are suffering from skin problems.

Hygiene kit distribution shall follow sector agreed standards to ensure that the most essential hygiene needs are covered. In host community settings where people living in fix housing conditions the feasibility and cost-effectiveness of introducing hygiene vouchers should be alternatively assessed.

Humanitarian WASH agencies shall identify mechanisms to support households in accessing essential hygiene items as well as sufficient water for diseases prevention but also to ensure people’s feeling of wellbeing and dignity.

PER

SON

AL

HY

GIE

NE

More than half of the assessed refugee population report difficulties to bath. Main barriers for bathing are the cost of soap and lack of water.

Key times for hand washing are “before cooking food” and “whenever they look / feel dirty”, only 43% report to wash their hands before eating.

People use water and soap for hand washing (84%) which has been mainly confirmed through the household observation (soap was in 75% of assessed households present.)

A considerable number (45%) reports to face hand washing issues which is primarily due to the cost of soap (34%) and lack of water (24%).

Hygiene promotional activities should focus on raising awareness about crucial hand washing times and the importance of hand washing for diseases prevention. For the existing knowledge- behaviour gap the appropriate behaviour change communication strategy needs to be identified.

Generally, when planning any hygiene promotional activities they need to take into account that this emergency response takes place in a middle income context in which the crisis affected population is mainly well educated and aware about their preferences.

Public health promotion strategies for host community settings need to be differentiated when targeting people living in standard accommodation or those in tent-based communities.

SAN

ITA

TIO

N

A large majority use the municipal solid waste system (84%), more than a half of those households (55%) uses it to avoid any spread of diseases.

Most of the survey participants rate the condition of their toilets as “good” (72%). The main issue observed is the bad smell (15%).

Agencies should investigate further in sanitation conditions and assessing toilet issues reported by the targeted population. The decision whether to give infrastructural support at household level needs be carefully analysed as any household improvement work also risks resulting in an increased rental price and falls actually rather under the responsibility of the respective landlord.

Smaller plumber work can be carried out, for example by providing capacity building of local associations and spare parts for the

36

toilet structure (flush repairmen, seat etc.). In case that household assessment reveals broken or leaking sewer systems, any work should be undertaken in collaboration with the respective authority to increase the awareness about potential contamination of water supply networks, taking as well into account the mobility of the refugee population.

FOO

D C

ON

SUM

PTI

ON

Food is mainly purchased through cash or WFP food vouchers, a larger percentage also reports to use credit. The food consumption pattern is likely to change especially for those household which are unregistered or awaiting registration as they do not have access to WFP vouchers or cash.

More than half of the survey respondents (65%) indicate to eat less than compared to Syria. Regardless the age, people have mostly three meals a day.

The crisis affected population is still able to maintain an acceptable level of nutritional dietary balance. Reducing the average number of meals is not yet an applicable coping strategy.

When dealing with an extensive number of refugees not having access to legal employment the situation risks to worsen as current coping strategies (loans from relatives / shop owners, selling assets etc.) will be soon exhausted. Further advocacy work needs be undertaken to draw more attention on the current risk situation of Syrian refugees in order to raise more funding for this population group and facilitating the access to livelihood opportunities.

HEA

LTH

During the survey period children were mainly suffering from ARI, followed by diarrhoea. Skin infections are mainly reported by adults.

The knowledge level of diarrhoeal transmission routes is poor, especially in terms of faeces and dirty hands.

The survey population treat diarrhoea among young children either at clinics level or through rehydration.

During the summer months when water supply is likely to be insufficient the prevalence of skin diseases is estimated to be higher across all age groups. Hygiene promotion approaches shall consider developing together with the targeted communities’ key actions to maintain the personal hygiene whilst the hardware side seeks to increase access to water and basic hygiene items.

Hygiene promotion should focus on diarrhoea prevention through increasing knowledge about transmission routes in a creative an d participatory manner.

CO

MM

UN

ICA

TIO

N

The majority of survey respondents (61%) access health information through informal channels such as family and/or friends or community discussions, although most of them express the preference to receive such information through TV spots /shows or in hospitals / clinics.

The planning of hygiene promotion should still consider the importance of community discussions and apply a participatory approach but be combined with mass messaging using TV channels for example for larger public health campaigning.

Hospitals and clinics should be actively integrated in the promotional activities by organising specific community discussions to epidemiological data patterns and / or according to subjects people express their main interest in (reproductive health, water-born related diseases etc.).

37

Inco

me

an

d e

xpen

dit

ure

Most households reported expenditure

rates that exceeded their income, indicating that the refugee population’s current arrangements in host communities is unsustainable and that coping mechanisms and resilience resources are being stretched. The burden is greatest in lower income households where the difference between income and expenditure rates is greatest.

Respondents reported high levels of dependence on humanitarian assistance, but with differential access reported geographically.

Food and rent are the two primary categories of expenditure.

Given the large difference between expenditure on food and rent as compared to meeting needs for household items and medical/health needs – it implies that trade-offs are being made with essential needs such as water and hygiene items.

Cash assistance is a relevant and appropriate form of assistance to address vulnerability.

Food and rent assistance are key target areas for support

WASH-related NFI distributions (hygiene items, water, etc) are appropriate as they are not currently being prioritised in respondent’s expenditure prioritisation.